Gathering basic intake history is standard procedure both with new patients and returning patients beginning new episodes of care. But standard procedure doesn't guarantee a standard intake. Listen closely, or you might miss the verbal cues that indicate the need for more specialized documentation:
"I just haven't been the same since that big box fell on me at the store." Is this work- or shopping-related? Is someone else or a disability policy liable for treatment costs? Are attorneys involved? CAs should ensure personal injury or workmen's comp paperwork is completed, and inform the doctor.
"I've been to so many doctors before--I hope you guys can help." Are these "many" doctors listed on the past history form? Interview the patient for the missing info. Consider asking for outside records.
"I haven't been driving much since my car accident a few months ago." Bring out the motor vehicle accident paperwork, even if the case appears to be settled and you're not being asked to bill a third party.
"I was hurt on the job, but my boss didn't believe me, so I'll have to use my own health insurance." Get the advanced notices ready for non-coverage by the insurance company and complete work injury paperwork. Request a copy of an official notice of non-compensable injury from the workplace or the worker's comp carrier.
"The doctor's been really helping my lower back, but now my neck hurts?" This is a new complaint from an existing patient, and must be evaluated just as the original presenting complaint. Establish protocol and procedure for gathering the correct data before the patient sees the doctor.
It's easy to get into the habit of autopilot and forget to attend to what patients are telling us. Listen--don't merely hear. And then properly document it. Because if it's not written down, it wasn't said and it didn't happen!
Subscribe to Paperwork Pearls.